For its own sake, hectic anesthesia care often lacks undue attention to biomedical ethical issues. Although routine behavior often involves balancing risks and benefits and giving patients the care they are willing to receive, the ethical principles of autonomy, goodwill, and harmlessness are not terms that must be used routinely. These principles receive more attention when dealing with end-of-life decisions, as they do when a terminally ill patient is admitted to the operating room, when life-sustaining treatment needs to be withdrawn, and when a transplant organ is removed from a cadaveric donor. (i) End-of-Life Care The most important feature of the last few decades has been the tremendous progress made in technology, pharmacology and medical health in general. The population is aging and medical conditions that once had to be abandoned are now finding treatments that can extend life for a significant period of time. Previously, in-hospital deaths usually occurred after all possible efforts had been tried. Nowadays, in-hospital deaths are more common when such decisions are made – not necessarily every possible resuscitative measure is taken. The decision to limit treatment by refusing or withdrawing treatment is often made in the course of treating patients at the end of life. （The most fundamental decision related to end-of-life care is probably the decision to refuse advanced cardiac life support when cardiac arrest occurs. not an indication for the application of CPR. Although this was not conceptually difficult to understand, earlier orders to refuse CPR or to forgo CPR were made verbally and not documented. As time progressed a more reasonable understanding developed that life-sustaining treatment such as CPR may not always be the right thing to do, as well as a recognition of the difference between sustaining life and prolonging the dying process. CPR is refused for two reasons: it is not medically appropriate, and the patient refuses similar treatment despite the healthcare team’s belief that it is medically appropriate. Ethically, there is no obligation to provide treatment if it is not beneficial to the patient, especially those treatments that are considered harmful or can cause suffering. Likewise, patients can refuse treatment that we offer that is deemed appropriate because we want to respect patient autonomy. Conflicts often arise when patients who have waived resuscitation orders are admitted to the operating room for surgical procedures and anesthesia. Cardiac arrest is one of the recognized risks of anesthesia, and surgeons will do everything possible to resolve problems that arise as a result of their treatment. There was a time when there was a pattern of a general pause in giving up resuscitation orders while the patient was under anesthesia in the operating room. This approach is now being reconsidered and replaced by a more patient-centered, individualized approach and methodology – with purposeful, procedural choices. The reevaluation process of waiving resuscitation orders in preference to surgical orders is also applicable to pediatric patients. The American Society of Anesthesiologists recommends the development of guidelines that provide four options that require reconsideration of the decision to waive resuscitation orders and indications for the use of operative and anesthetic drugs. (iii) WithdrawalofTreatment When organ failure is sufficiently life-threatening, life-sustaining treatment is usually initiated. When the underlying disease is corrected and organ function is restored, life-sustaining treatment no longer needs to continue and can be discontinued. This is common when a patient has temporary pulmonary insufficiency requiring mechanical ventilation after surgery and without this support the patient is at risk of death. However, if organ function has not been restored or the patient’s condition has deteriorated further and it may become apparent that survival is not possible, it is correct to consider discontinuing life-sustaining treatment, as it may simply delay death or prolong the process.49 Even if life-sustaining treatment is discontinued, it is still the physician’s responsibility to care for the dying patient, to administer certain comforting medications, and to ensure that other dignifying treatments will still continue. Often the drugs used for comfort also have a sedative effect, which can hasten death and have a dual effect. Such medications should be used even if they hasten death in order to relieve the patient’s suffering. Some patients have signed orders or living wills to their physicians, specifically expressing their wishes regarding the use of life-sustaining treatment when they are in a terminal or irreversible condition and unable to express their wishes. The most common order is for treatment to be discontinued and for the patient to die a natural death, although other orders will be given. An order to discontinue or refuse life-sustaining treatment can be described as a refusal of treatment with informed consent. Orders to limit life-sustaining treatment are often given to patients who lack capacity, even in the absence of a written order. Family members who are involved in the consent process in a different way may be involved in discussions about discontinuing life-sustaining treatment. Sometimes they may have a better understanding of the patient’s specific requirements at this point, but even if these requirements are never clearly expressed, the decision can still be made on the basis of the patient’s values and what is in his or her best interest. (iv) Futility Sometimes patients, and more commonly family members, request the application of medically inappropriate treatment.50 Treatment aimed at a cure is considered worthless when the patient has no hope of surviving. Although there is no duty to provide ineffective treatment, terminating such treatment requested by the family and with the subsequent death of the patient after discontinuation is something physicians are reluctant to do. Clinical ethics counseling is necessary and may be helpful in resolving such issues. Certain institutions and state laws provide statutory procedures to discontinue ineffective life-sustaining treatment even if it is contrary to the patient’s or family’s request, and such actions are protected from a legal standpoint. (v) Organ donation after cardiac death In the past, organs for transplantation were removed from patients promptly after cardiac death, but this practice is largely prohibited due to the development of the concept of brain death. Anesthesiologists are often required to perform a number of operations on brain-dead cadaveric organ donors during surgical procedures.55 This procedure is different from most cases in that the application of anesthetic drugs is somewhat unique in that it is not necessary for the patient to feel no pain, and once the heart stops, the anesthesiologist’s operation is considered complete while the procedure is in progress, even though the surgery continues. The large demand for transplant organs and the increased public awareness of organ donation have once again generated interest in organ donation after cardiac death. Sometimes there is an option where a patient who is dying but still has a functioning transplantable organ – such as a kidney or liver – has to make a decision about its life-sustaining treatment. The end-of-life process usually occurs in the ICU and involves the use of certain medications to relieve the patient’s pain while life-sustaining treatment is withdrawn. Transferring this process to the operating room allows for control of the environment surrounding death and the removal of organs that can be used for transplantation. Understandably, those working in the environment at the time of surgery would be disturbed by this event. They will need to reconsider exactly what is happening and should avoid the process if needed. Although death occurs after discontinuation of life-sustaining treatment and the use of comfort medication, the reason for death is not to obtain a transplanted organ. “Dead donor guidelines,” as with brain dead donors, apply in this case and prohibit actions that result in death in order to obtain an organ. Anesthesia specialists have declined the opportunity to be involved in this process. It is more common for the ICU physician in charge of the patient’s care to be involved at the same time as opposed to the anesthesiologist being involved in the end-of-life process alone. Whether or not anesthesiologists are directly involved in the process, they are right to be involved in the hospital policy-making process and should be committed to ensuring that the dignity and comfort of the patient is protected from start to finish.